Early dysphagia rehabilitation in critical care: A pilot study of safety, feasibility, and effectiveness of a strength-based dysphagia treatment protocol in intensive care unit–acquired weakness

Background Dysphagia is commonly associated with intensive care unit–acquired weakness (ICUAW), with oropharyngeal muscular weakness considered a major precipitating factor. Unfortunately, evidence for effective rehabilitation of dysphagia associated with ICUAW is lacking. Aim The aim of this study was to examine the feasibility, safety, and effectiveness of a strength-based dysphagia treatment protocol for patients with dysphagia associated with ICUAW. Methods A prospective pilot cohort study was conducted on all critically ill patients admitted to an Australian tertiary referral intensive care unit (ICU) over a 3-year period, diagnosed with dysphagia and ICUAW. A strength-based dysphagia treatment protocol was implemented incorporating expiratory muscle strength training and swallowing exercises to target the tongue base, pharyngeal, suprahyoid, and respiratory muscles. A regime of five sets of five repetitions, conducted 5 days per week, was employed. Treatment commenced in the ICU, continuing until swallowing recovery or swallowing function plateaued. Key swallowing and respiratory outcomes were collected weekly: clinical swallow examination (Functional Oral Intake Scale [FOIS]: 1–7), flexible endoscopic evaluation of swallowing (New Zealand Secretion Scale: 0–7, Penetration–Aspiration Scale: 1–8] Yale Pharyngeal Residue Scale [Yale]: 1–5), peak expiratory flow (PEF), and maximum expiratory pressure (MEP). Results Thirteen participants (11 male, median age=52 years) were recruited. Medical diagnoses included severe burn injury, influenza-A, necrotising pancreatitis, sepsis, and COVID-19 infection. Median mechanical ventilation was of 19 days (interquartile range [IQR] = 16–36 days), ICU length of stay was of 34 days (IQR = 21–43 days), and hospital length of stay was of 71 days (IQR = 43–86 days). Four required tracheostomy (median: 18 days, IQR=13–24 days). All participants exhibited profound dysphagia (FOIS = 1–3, New Zealand Secretion Scale=3–7, Penetration–Aspiration Scale=3–8, Yale Pharyngeal Residue Scale=2–5) and respiratory impairment at baseline (MEP = 21–114 cmH 2 O, PEF=80–310 L/min). All completed the treatment protocol and achieved premorbid diet and fluids (FOIS = 7) and functional respiratory status (MEP = 62–178 cmH 2 O, PEF=260–520 L/min) by hospital discharge. No adverse events were recorded. Conclusions Pilot study findings suggest that a strength-based dysphagia treatment protocol for patients with ICUAW and dysphagia is safe and feasible with promising outcomes indicating that it may support dysphagia recovery in this challenging population.